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Friday, March 18, 2011

General Surgery, Acute Care Surgery and the Surgical Hospitalist

As medicine adapts to the 21st century, new specialties arise. General surgery is seeing two new fields emerge. One is “Acute Care Surgery,” which encompasses three facets of general surgery—emergency surgery, critical care and trauma care. The other is the concept of a surgical hospitalist. That is, a surgeon works only in a hospital and has no office or private practice. The idea is similar to the medical hospitalist movement, which has existed for several years now.

The changes in surgery are in response to a number of forces. General surgeons are becoming increasingly more focused, especially in areas such as advanced laparoscopic surgery, bariatric (obesity) surgery, endovascular surgery and breast surgery. With these areas of concentration comes decreasing interest in taking emergency call, which interferes with elective cases and office practice. In addition, a concentration on something like breast surgery leads to diminished experience and skills in treating gunshot wound and bowel obstructions.

Acute Care Surgery arose in response to the need for emergency call coverage as well as the desire of trauma surgeons to increase their operative case load as trauma care itself becomes less involved with operative procedures. In many trauma centers, the percentage of blunt trauma cases is well over 90% and a large majority of these patients are treated without surgery. Many academic medical centers have established acute care surgery services which are staffed mostly by trauma/critical care surgeons.

A surgical hospitalist usually does acute care surgery but does not see outpatients unless they have emergencies. I have been working as a surgical hospitalist for the past two years. I am on duty for two five-day weekends per month. During that time I cover for the general surgeons in the area, make rounds on their inpatients, handle phone calls from their private practice patients, see consults from the emergency department and inpatient medical services and perform any emergency procedures that are needed. At the end of my tour of duty, I sign out my patients to one of the general surgeons. The positive features of my job are as follows: there is no office practice or overhead; it’s a salaried position; I have 20 days/month off; when I am not on duty, I am completely without responsibilities. The downsides include loss of continuity, having to pick up many patients often with complex problems all at once and occasionally having to leave a very sick patient for someone else to take care of. I am the sole surgical hospitalist at my institution, but there can also be groups which can cover inpatients and emergencies.

The surgical hospitalist model is a far cry from anything I would have dreamed of when I started in surgery years ago. But it is the wave of the future. Other specialties such as orthopedic surgery are getting on the bandwagon. The field will see much growth in the next few years as graduating residents, who are used to shift work, will see a surgical hospitalist career as a logical extension of their experience as residents.

11 comments:

I'm a 2nd year student and am currently drawn to EM and surgery. While I think I will like the lifestyle EM affords the work of a surgical specialist seems much more enticing. However, when reading about trauma surgery the largest deterrent is the obscene amount of hours even several years after your residency. I've read a few papers that suggest the transition to acute care surgery may create schedules similar to those of EM and the surgical hospitalist that you mentioned. Have you found this to be true?Can you recommend any good resources to read about the transition to acute care surgery vs the trauma surgeon model?

Sorry about the delay in responding. I was away and didn't have access to a computer most of the time.

Just to remind you that currently trauma surgery training lasts for two years and follows five years of general surgery residency. Many acute care surgery fellowships are appearing. They are also two years, usually incorporating a year of trauma/acute surgery and a year of critical care. I believe they will replace the "trauma fellowship" as we now know it. Still, it will be seven years total after medical school.

Here are two links to abstracts of recent papers. Your library should be able to provide you will full text versions. There are many other papers on this.

My hospital is thinking about starting an acute care surgery program. I have a couple of questions for you... How did you come up with 2 5-day weekends per month? At my hospital, 5 days of call in a row would be quite a feat. Are you the only surgical hospitalist at your hospital? Who pays your salary - hospital or private practice? How much is your pay, compared to a typical private practice general surgeon or MGMA benchmark? Thanks...

Two 5-day weekends was what the hospital requested. They wanted to give their general surgeons fewer weekends of call without bringing in a full-time surgeon to compete with them for elective cases. I am the only one doing this at my hospital.

The hospital pays me. They look at it as being analogous to paying their medical hospitalists. I am making slightly more than the MGMA average for a general surgeon.

Sometimes 5 straight days can be tough. I am, of course like many surgeons, a superman and I get through it. I do have time for naps. I don't think my performance has suffered as a result of the schedule even though it can be busy. For example, I have done 4 appendectomies and 2 cholecystectomies during the 3 previous days (4/15, 16 & 17).

20 days off a month? Is this standard for most hospitals hiring acute care surgeons? If so, this would be a dream come true... the lifesytle of an EM doc while maintaining my love for trauma and the OR. I may just have to change my ERAS application now....

Unfortunately, my schedule is not standard. It is unusual. I doubt there are many jobs like mine around. Most acute care surgeons belong to groups and are simply hospital-based. They may only be on call once every 5-7 days, depending on the size of the group. Otherwise, they work at least 10 hours/day on weekdays.

Popular view on my job is so distant from reality that I really feel ashamed to hear all those misconceptions. I used to be really proud of my job as a fresh resident and was willing to share it with practically anyone only to find out that a positive feedback is based on misperception of what I do while negative is unpleasant enough to be avoided. Now as more or less independent registrar I still feel proud but with a little more of experience I don't feel the urge to share it with anyone anymore. If asked for advice I do tell (which is almost true) that as I'm most of my time involved in acute care I really cant recommend my services as nobody sane would like to get into situation I can be helpful which usually does the trick. Good post, thank you.

This may sound silly, but for the five days you are in the hospital, are you there overnight every night? (Basically living in the hospital for five days straight since you are the only surgical hospitalist there?)

And secondly, are you aware how academic hospitals with acute care surgery services schedule their attending surgeons? My medical school's hospitals do not have ACS attendings but do have medical and pediatric hospitalists who work either 7 days on/7 days off or 14 on/14 off, with the "off" days being used for academic work. Would that be a similar model that more ACS services are using now? I found an survey in the latest Journal of Trauma and Acute Care Surgery (volume 78, number 1) that started to get into some of the structure of how services are set up, but thought I would ask.